Sexually Transmitted DiseasesKhalid Ibrahim, PharmD.University of MinnesotaOverview!Non-HIV STDs!Chlamydia!Gonorrhea!Epididymitis!Pelvic inflammatory disease (PID)!Vaginal infections!Syphilis!Chancroid!Pediculosis and scabies!Genital warts and human papillomavirus (HPV)!Genital herpesMMWR Morb Mort Wkly Rep, Vol. 47, RR-1, Jan 23, 1998.Overview (cont.)Tracts: scabies.Nits/Blue spots: liceHSV, scabiesTrauma, contact dermatitisHSV, syphilisWarts, scabies, molluscumsyphilisHSV, syphilis, trauma, chancroid, gonorrhea, trich-omoniasis Misc.CrustsDiffuse erythemaVesicles and BullaePapulesUlcersImages available at www.healthac.orgOverview (cont.)Sexual assault!STDs most frequently Dx’d!Trichomoniasis!Vaginosis!Chalmydial infections!Gonorrhea!Px recommended post assault: !Ceftriaxone125 mg IM in a single dose,PLUS!Metronidazole2 g orally in a single dose,PLUS!Azithromycin1 g orally in a single dose or Doxycycline100 mg orally twice a day for 7 days.ChlamydiaEpidemiology!Epidemiology per site !Ocular disease!500 million worldwide affected!7-9 million worldwide blind!Genital tract infections even more prevalent!CDC estimate of 4 million cases annually (US) !Recovered more often in women exposed to gonorrhea.!More C. trachomatis shedding in co-infectedChlamydiaPathogenesis!Sites!Genital tract (NGU)!Ocular!Lung (pneumonia)!Spread via lymph system / multiply inside mononuclear phagocytes !Tissue damage!Initial infections !Recurrent infections: strong immune response!Ocular trachoma !Asymptomatic partner – less likely transmissionChlamydiaDiagnosis!Laboratory findings!Cytologic examination (intracytoplasmic inclusions)!Isolate of C. trachomatis !ELISA anti-Chlamydia antigen!Direct hybridization / amplification to detect specific nucleic acid!Serology (compliment fixation)!Microimmunofluoresence (Aby)!Clinical presentationChlamydiaClinical presentation!4 categories!Perinatal!Infant conjunctivitis!Infant pneumonia !Ocular trachoma!Chronic follicular conjunctivitis!Recurrence common!scarring!Lymphogranuloma venereum (LVG)!Primary lesion "lymphadenopathy + systemicinflammatory mass (bubo)!Third stage: hypertrophic chronic granulomas, ulceration of external genitalia, lymphatic obstruction (elephantitis)ChlamydiaClinical presentation (cont)! Other ocular/genital infections! Ocular manifestations similar to early trachoma, but without serious complications! Genital infections!Urethritis (NGU)!Epididymitis and prostatitis !Proctitis and proctocolitis!Sexually reactive arthritis!Cervicitis!Endometritis!PID!Pregnancy complicationsChlamydiaNGU!Asymptomatic common! Yet 30-50% NGU due to C. trachomatis! Others: 10-20%U. urealyticum, T. vaginalisWhite/clear/gray dischargePurulent discharge4 day incubation7-14 day incubationChlamydia NGUGonococcal urethritis4 or more PMNs per 1000X field to Dx urethritis. Lack of N. gonorrhea" NGU.Positive leukocyte esterase also indicative of urethritisChlamydiaPregnancy complications!Largest published study! Analysis of pregnancy outcomes in 1110 women (infected but not tx’d), 1323 (tx’d with erythromycin), 9111 uninfected (untx’d) women. ! Significant association in premature membrane rupture (odds ratio 0.56).Am J Obstet Gynecol. 1990;162:34-39.ChlamydiaCA risk!Most recent study! Longitudinal, nested case-control study (530,000 women)! 128 cases of squamous cell carcinoma! Risk for SCC development linked to IgG abys of C. trachomatis . Most heavily with serotype G, followed by I and D. JAMA. 2001; 285: 47-51ChlamydiaTreatment!Uncomplicated genital tract infxn! Doxycycline 100 mg PO BID x7d! Azithromycin 1 g x1! Ofloxacin 300 mg BID x7d!Pregnant women! Erythromycin 500 mg QID x7d! Amoxicillin 500 mg TID x7-10d!Trachoma vaccineGonorrheaEpidemiology!Approximately 1 million new infections annually!Underreported (? Undertreated)!ResistanceGonorrheaClinical presentation!Genital infections!Urethritis!Typically in males!Dysuria, frequency, purulent discharge!Untreated spontaneous resolution in few weeks!Cervicitis!Most common gonococcal infection in females!Dysuria, frequency, vaginal discharge, uterine bleeding!Typically asymptomatic until complications (PID)GonorrheaClinical presentation (cont)!Other infections! Oropharyngeal! Typically asymptomatic! More common in females + homosexual men! Rectal! Typically asymptomatic! Constipation, itchingGonorrheaComplications!Pelvic inflammatory disease (PID)!Epididymitis, prostatitis!Opthalmia neonatorum!Premature rupture of membranes!1sttrimester!Disseminated infections!Dermatitis!Arthritis!Endocarditis!meningitisGonorrheaDiagnosis!Gram stain! G (-) intracellular diplococciGonorrheaTreatment!Uncomplicated infections3rdgen. ceph or FQCefixime 400 mg PO X1Ceftriaxone 125 mg IM X1Ciprofloxacin 500 mg PO X1Ofloxacin 400 mg PO X1PLUS anti-chlamydialAzithromycin 1 gm X1Doxycycline 100 mg PO BID X7Gonorrhea Treatment (cont.)!Disseminated infections!Also to be given with anti-chlamydial tx!Ceftriaxone 1 g IM/IV q24h!Alternatives!Cefotaxime 1 g IV q 8h!Ceftizoxime 1 g IV q 8h!β-lactam allergic!Ciprofloxacin 500 mg IV q 12h!Ofloxacin 400 mg IV q 12h!Spectinomycin 2g IM q 12h!Continue IV for 1-2 days post clinical improvement, then switch to PO!Cefixime, Cipro, OfloxGonorrheaTreatment (cont.)!Gonococcal meningitis and endocarditis! Ceftriaxone 1-2 g IV q 12 h! 10-14 days for meningitis! Minimum 4 weeks for endocarditis!Prophylaxis! Silver nitrate 1% soltn. X1! Erythromycin 0.5% ointment X1! Tetracycline 1% ointmentX1EpididymitisEpidemiology!Acute cases in men <35 yrs! Typically caused by C. trachomatis! Possibly caused by N. gonorrhea!Older men with urinary tract instrumentation (non-STD)! Enteric G (-)! PseudomonasEpididymitisTreatment!See Chlamydia and Gonorrhea sections!Unidentified organism! OfloxacinPelvic inflammatory disease (PID)Epidemiology!Estimated 1 million cases annually!Risk factors!Youth!Multiple sex partners!IUD use!? Douching!Spectrum of inflammatory disorders!Endometritis!Salpigitis!Tubal ovarian abscesses !Pelvic peritonitisPIDEpidemiology (cont.)!Causative organisms!C. trachomatis!N. gonorrhea!G. vaginalis, anaerobes, enteric GNB, S. agalactiaePIDClinical issues!Presentation!Variable!Lower abdominal tenderness (often bilateral)!General aches!Vaginal discharge!Complications!Tubal damage + scarring" ectopic pregnancy!Sepsis!Chronic pelvic pain!RecurrencePIDDiagnosis!Minimal criteria!Lower abdominal tenderness!Tenderness with motion of cervix !Adnexal tenderness!Additional criteria!Fever,